NURSING 101 PROCEDURE CHECKLIST

Name of Student______________________________ Name of Evaluator(s)________________________________

Date(s)____________________________

First attempt = 10 points, second attempt = 5 points, three or more attempts = 0 points. Competency still must be
complete to be satisfactory in course.

**IN ORDER TO BE SATISFACTORY, THERE MUST BE NO MORE THAN 2 RECOGNIZED BREAKS IN

STERILE TECHNIQUE.

**ANY UNRECOGNIZED BREAKS IN STERILE TECHNIQUE RESULTS IN AN UNSATISFACTORY.

STERILE DRESSING CHANGE:

*Indicates must be performed in order to be Satisfactory
PROCEDURE STEPS #1 #2 #3 Comments
Assessments must be completed within 30 minutes S U S U S U
For all assessments:
1. KITES (MUST check ID band*)
2. Positions patient appropriately
3. Asks appropriate health questions
4. Is able to answer questions related to
assessment
5. Document your findings (does not count in
allotted time)
6. Addresses patient by proper name and
conversation is therapeutic at all times.
7. Uses good body mechanics: positions bed or
over bed table to a working level.
8. After the procedure:
a. Evaluates patient’s response to the
procedure.
b. *Leaves patient in a comfortable, safe
position (safety checks) with call light
within reach.*
Specific skill: Removing an old dressing,
cleansing a wound, applying a dry sterile
dressing
9. Washes hands and applies clean gloves.
10. Loosens edges of tape of the old dressing.
Stabilizes the skin with one hand while
pulling the tape in the opposite direction.
11. Beginning at the edges of the dressing, lifts
the dressing toward the center of the wound.
12. If the dressing sticks, moistens it with 0.9%
normal saline before completely removing it.
13. Observed removed dressing for drainage,
especially noting amount, color and odor (if
 any) of drainage.
14. Disposes of soiled dressing and gloves in a
biohazard bag. Removes gloves and performs
hand hygiene.
15. *Opens sterile dressing supplies and sterile
gloves using sterile technique. Recognizes and
verbalizes action if contamination occurs. *
16. *Applies sterile normal saline from bottle or
prefilled syringe onto sterile gauze or cotton
balls using sterile technique *
17. *Dons sterile gloves without contaminating or
recognizing contamination*
a. Grasped folded edge of cuff of one glove.
b. Lifted glove above wrapper and away from
body.
c. Slid opposite hand into glove. Did not adjust
cuff or fingers at this time or let ungloved
hand touch outside of glove.
d. Picked up second glove by sliding sterile
gloved fingers under cuff edge. Keeps
gloved thumb off cuff of second glove.
e. Slid fingers of opposite hand into glove. Let
go of edge when hand in glove.
f. Adjusted for comfort and fit.
18. *Uses sterile cotton balls or gauze to cleanse
wound: “Clean to dirty” and “top to bottom”*
a. Cleans incision line first going from top to
bottom
b. Cleans along each side of incision with a
separate cotton ball, going from top to
bottom.
19. Picks up new sterile dressing and places over
center of wound.
20. Places large sterile ABD dressing over the
wound dressing.
21. Secures edges of dressing to skin with tape.
22. Places date, time, and initials on dressing.
23. Removes gloves and performs hand hygiene.
24. *Maintained principles of sterile field eg.,
anything below the waist is unsterile, sterile
field always in field of vision (do not turn back
toward sterile field), keep sterile gloved
hands above the waist, no reaching across
sterile field, do not use wet or damaged
package of sterile supplies, cannot touch an
unsterile object with sterile gloves, etc.*
DOCUMENTATION OF PROCEDURE (Use back of sheet if necessary):

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